Benefit-cost analysis of iron fortification of rice in India: modelling potential economic gains from improving haemoglobin and averting anaemia

Qureshy, Lubina and Alderman, Harold and Manchanda, Navneet (2023): Benefit-cost analysis of iron fortification of rice in India: modelling potential economic gains from improving haemoglobin and averting anaemia. Published in: Journal of Development Effectiveness No. https://doi.org/10.1080/19439342.2023.2168728

Abstract

This paper presents an ex-ante Benefit-Cost analysis of proposed fortification of extruder rice with iron under the social safety net in India. The benefits of iron fortification are estimated in terms of economic gains from increases in current work productivity among adults and future productivity from improvements in learning among school-going children. The base case scenario indicates a benefit cost ratio of 8.2, with 69 percent coming from improved learning in school and the remainder through enhanced work productivity. Benefit-cost ratios are also presented for a range of alternative assumptions, all of these resulting in ratios greater than 1. Nevertheless, despite decades of fortification at scale, a principal conclusion of this study is that future benefit cost models would gain confidence if more evidence is generated on the relationship of improved biomarkers for iron and changes in measures of cognition and labour productivity.

• Item Type: MPRA Paper
• Language: English
• Keywords: Cost-benefit; fortification; anaemia; school meals; productivity
• Subjects: I - Health, Education, and Welfare > I1 - Health > I15 - Health and Economic Development; Q - Agricultural and Natural Resource Economics ; Environmental and Ecological Economics > Q1 - Agriculture > Q18 - Agricultural Policy ; Food Policy

References

Alderman, H., U. Gentilini, and R. Yemtsov. 2018. The Evolution of Food as Social Assistance. The 1.5 Billion People Question. Washington DC: World Bank. [Google Scholar]

Alderman, H., and S. Linnemayr. 2009. “Anemia in Low-Income Countries is Unlikely to Be Addressed by Economic Development Without Additional Programs.” Food and Nutrition Bulletin 30 (3): 265–269. doi:10.1177/156482650903000308. [Crossref], [Web of Science ®], [Google Scholar]

Alesina, A., P. Giuliano, and N. Nunn. 2013. “On the Origins of Gender Roles: Women and the Plough.” The Quarterly Journal of Economics 128 (2): 469–530. doi:10.1093/qje/qjt005. [Crossref], [Web of Science ®], [Google Scholar]

Banerjee, A., S. Barnhardt, and E. Duflo. 2018. “Can Iron-Fortified Salt Control Anemia? Evidence from Two Experiments in Rural Bihar.” Journal of Development Economics 133: 127–146. doi:10.1016/j.jdeveco.2017.12.004. [Crossref], [Web of Science ®], [Google Scholar]

Basta, S. S., D. Karyadi, and N. S. Scrimshaw. 1979. “Iron Deficiency Anemia and the Productivity of Adult Males in Indonesia.” The American Journal of Clinical Nutrition 32 (4): 916–925. doi:10.1093/ajcn/32.4.916. [Crossref], [Web of Science ®], [Google Scholar]

Blakstad, M. M., J. E. Nevins, S. Venkatramanan, E. M. Przybyszewski, and J. D. Haas. 2020. “Iron Status is Associated with Worker Productivity, Independent of Physical Effort in Indian Tea Estate Workers.” Applied Physiology, Nutrition, and Metabolism 45 (12): 1360–1367. doi:10.1139/apnm-2020-0001. [Crossref], [Web of Science ®], [Google Scholar]

Britto, P. R., S. J. Lye, K. Proulx, A. K. Yousafzai, S. G. Matthews, T. Vaivada, R. Perez-Escamilla, et al. 2017. “Nurturing Care: Promoting Early Childhood Development.” The Lancet 389 (10064): 91–102. doi:10.1016/S0140-6736(16)31390-3. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]

Bundy, D. A., N. de Silva, S. Horton, G. C. Patton, L. Schultz, D. T. Jamison, A. Abubakara, et al. 2018. “Investment in Child and Adolescent Health and Development: Key Messages from Disease Control Priorities.” The Lancet 391 (10121): 687–699. doi:10.1016/S0140-6736(17)32417-0. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]

Chong, A., I. Cohen, E. Field, E. Nakasone, and M. Torero. 2016. “Iron Deficiency and Schooling Attainment in Peru.” American Economic Journal Applied Economics 8 (4): 222–255. doi:10.1257/app.20140494. [Crossref], [Web of Science ®], [Google Scholar]

Christian, P. 2021. “Anemia in Women—an Intractable Problem That Requires Innovative Solutions.” Nature medicine 27 (10): 1675–1677. doi:10.1038/s41591-021-01514-3. [Crossref], [Web of Science ®], [Google Scholar]

Cyriac, S., R. Haardorfer, L. M. Neufeld, A. W. Girard, U. Ramakrishnan, R. Martorell, and M. N. N. Mbuya. 2020. “High Coverage and Low Utilization of the Double Fortified Salt Program in Uttar Pradesh, India: Implications for Program Implementation and Evaluation.” Current Developments in Nutrition 4 (9): nzaa133. doi:10.1093/cdn/nzaa053_026 [Crossref], [Web of Science ®], [Google Scholar]

Das, J. K., R. A. Salam, R. Kumar, and Z. A. Bhutta. 2013. “Micronutrient Fortification of Food and Its Impact on Woman and Child Health: A Systematic Review.” Systematic Reviews 2 (1): 1–24. doi:10.1186/2046-4053-2-67. [Crossref], [Google Scholar]

DFPD, 2019. “Ministry of Consumer Affairs, Food and Public Distribution. Government of India. Operational Guidelines of Fortification of Rice and Its Distribution Under PDS. Operational Guidelines Ono Pilot Scheme for Fortiication of Rice and Its Distribution Under Pds.Pdf.” (accessed on 20 April 2021) [Google Scholar]

DFPD, 2020. Ministry of Consumer Affairs, Food and Public Distribution. Government of India. Revision in the Pilot Scheme on “Fortification of Rice & its Distribution under the Public Distribution System”. Letter to all States/UTs. [Google Scholar]

DFPD. 2021. Ministry of Consumer Affairs, Food and Public Distribution. Government of India. Food Grain Bulletin. (accessed on 16 April2021). https://dfpd.gov.in/writereaddata/Portal/Magazine/FoodgrainBulletinApril2021.pdf [Google Scholar]

Edgerton, V. R., G. W. Gardner, Y. Ohira, K. A. Gunawardena, and B. Senewiratne. 1979. “Iron-Deficiency Anaemia and Its Effect on Worker Productivity and Activity Patterns.” British Medical Journal 2 (6204): 1546–1549. doi:10.1136/bmj.2.6204.1546. [Crossref], [PubMed], [Google Scholar]

Ekström, E. C., S. Z. Hyder, A. M. R. Chowdhury, S. A. Chowdhury, B. Lönnerdal, J. -P. Habicht, and L. Å. Persson. 2002. “Efficacy and Trial Effectiveness of Weekly and Daily Iron Supplementation Among Pregnant Women in Rural Bangladesh: Disentangling the Issues.” The American Journal of Clinical Nutrition 76 (6): 1392–1400. doi:10.1093/ajcn/76.6.1392. [Crossref], [Web of Science ®], [Google Scholar]

Engle‐Stone, R., S. A. Vosti, H. Luo, J. Kagin, A. Tarini, K. P. Adams, C. French, and K. H. Brown. 2019. “Weighing the Risks of High Intakes of Selected Micronutrients Compared with the Risks of Deficiencies.” Annals of the New York Academy of Sciences 1446 (1): 81. doi:10.1111/nyas.14128. [Crossref], [Web of Science ®], [Google Scholar]

Evans, D. K., and F. Yuan. 2019. “Equivalent Years of Schooling: A Metric to Communicate Learning Gains in Concrete Terms.” World Bank Policy Research Working Paper (8752). [Google Scholar]

Fiedler, J. L., S. Babu, M. Smitz, K. Lividini, and O. Bermudez. 2012. “Indian Social Safety-Net Programs as Platforms for Introducing Wheat Flour Fortification: A Case Study of Gujarat, India.” Food and Nutrition Bulletin 33 (1): 11–30. doi:10.1177/156482651203300102. [Crossref], [Web of Science ®], [Google Scholar]

Gera, T., H. S. Sachdev, and E. Boy. 2012. “Effect of Iron-Fortified Foods on Hematologic and Biological Outcomes: Systematic Review of Randomized Controlled Trials.” The American Journal of Clinical Nutrition 96 (2): 309–324. doi:10.3945/ajcn.111.031500. [Crossref], [Web of Science ®], [Google Scholar]

GoI (Government of India). 2022 Anemia Mukt Bharat. (accessed on 23 July 2022). https://anemiamuktbharat.info/ [Google Scholar]

Hanushek, E. A., and L. Wöessmann. 2010. “Education and Economic Growth.” In International Encyclopedia of Education, edited by P. Peterson, E. Baker, and B. McGaw, 245–252. Vol. 2. Oxford: Elsevier. [Crossref], [Google Scholar]

Harberger, A. C. 1997. “New Frontiers in Project Evaluation? A Comment on Devarajan, Squire, and Suthiwart-Narueput.” The World Bank Research Observer 12 (1): 73–79. doi:10.1093/wbro/12.1.73. [Crossref], [Web of Science ®], [Google Scholar]

Heidkamp, R. A., E. Wilson, P. Menon, H. Kuo, S. Walton, G. Gatica-Domínguez, I. Crochemore da Silva, T. Aung, N. Hajeebhoy, and E. Piwoz. 2020. “How Can We Realise the Full Potential of Health Systems for Nutrition?” The BMJ 368: l6911. doi:10.1136/bmj.l6911. [Crossref], [Google Scholar]

Horton, S., H. Alderman, and J. Rivera. 2009. “The Challenge of Hunger and Malnutrition Lomborg, Bjorn.“Global Crises, Global Solutions: Costs and Benefits 2nd (New York: Cambridge University Press) 305–354. [Crossref], [Google Scholar]

Horton, S., and J. Ross. 2003a. “Corrigendum To: ‘‘The Economics of Iron Deficiency.” Food Policy 32 (2007): 141–143. Food Policy 28 (2003) 51–75. doi:10.1016/j.foodpol.2006.08.002. [Crossref], [Google Scholar]

Horton, S., and J. Ross. 2003b. “The Economics of Iron Deficiency.” Food Policy 28 (1): 51–75. doi:10.1016/S0306-9192(02)00070-2. [Crossref], [Web of Science ®], [Google Scholar]

Horton, S., A. Wesley, and M. V. Mannar. 2011. “Double-Fortified Salt Reduces Anemia, Benefit: Cost Ratio is Modestly Favorable.” Food Policy 36 (5): 581–587. doi:10.1016/j.foodpol.2011.06.002. [Crossref], [Web of Science ®], [Google Scholar]

Hurrell, R. 2018. “Efficacy and Safety of Iron Fortification. In: Mannar, M. G. V., Hurrell, R. F. eds. .Food Fortification in a Globalized World, 195–212. London: Academic Press. [Crossref], [Google Scholar]

Hurrell, R. 2021a. “Iron Fortification Practices and Implications for Iron Addition to Salt.” The Journal of Nutrition 151 (Supplement_1): 3S–14S. doi:10.1093/jn/nxaa175. [Crossref], [Google Scholar]

Hurrell, R. 2021b. “The Potential of Iodine and Iron Double-Fortified Salt Compared with Iron-Fortified Staple Foods to Increase Population Iron Status.” The Journal of Nutrition 151 (Supplement_1): 47S–63S. doi:10.1093/jn/nxaa204. [Crossref], [Google Scholar]

Indian Institute for Population Sciences (IIPS) and MoHfw. 2021. National Family Health Survey – 5. 2019-2021. (accessed on 23 July 2022) http://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf [Google Scholar]

Indian Institute for Population Sciences (IIPS) and MoHFW. National Family Health Survey - 4. 2021. (accessed on 16 April 2021). http://rchiips.org/nfhs/pdf/NFHS4/India.pdf [Google Scholar]

Keats, E. C., L. M. Neufeld, G. S. Garrett, M. N. Mbuya, and Z. A. Bhutta. 2019. “Improved Micronutrient Status and Health Outcomes in Low-And Middle-Income Countries Following Large-Scale Fortification: Evidence from a Systematic Review and Meta-Analysis.” The American Journal of Clinical Nutrition 109 (6): 1696–1708. doi:10.1093/ajcn/nqz023. [Crossref], [Web of Science ®], [Google Scholar]

Kraemer, K., and M. Zimmerman, edited by. 2007. Nutritional Anemia. Basel: Sight & Life Press. [Google Scholar]

Krämer, M., S. Kumar, and S. Vollmer. 2021. “Improving Child Health and Cognition: Evidence from a School-Based Nutrition Intervention in India.” The Review of Economics and Statistics 103 (5): 818–834. doi:10.1162/rest_a_00950. [Crossref], [Web of Science ®], [Google Scholar]

Kurpad, A. V., S. Ghosh, T. Thomas, S. Bandyopadhyay, R. Goswami, A. Gupta, P. Gupta, et al. 2021. “Perspective: When the Cure Might Become the Malady: The Layering of Multiple Interventions with Mandatory Micronutrient Fortification of Foods in India.” The American Journal of Clinical Nutrition 114 (4): 1261–1266. doi:10.1093/ajcn/nqab245. [Crossref], [Web of Science ®], [Google Scholar]

Li, R., X. Chen, H. Yan, P. Deurenberg, L. Garby, and J. G. Hautvast. 1994. “Functional Consequences of Iron Supplementation in Iron-Deficient Female Cotton Mill Workers in Beijing, China.” The American Journal of Clinical Nutrition 59 (4): 908–913. doi:10.1093/ajcn/59.4.908. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]

Low, M., A. Farrell, B. Biggs, and S. Pasricha. 2013. “Effects of Daily Iron Supplementation in Primary-School–aged Children: Systematic Review and Meta-Analysis of Randomized Controlled Trials.” Canadian Medical Association Journal 185 (17): E791–802. doi:10.1503/cmaj.130628. November 19, 2013. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]

Mahapatra, S., M. E. Parker, N. Dave, S. C. Zobrist, D. S. Arul, A. King, A. Betigeri, and R. Sachdeva. 2021. “Micronutrient-Fortified Rice Improves Haemoglobin, Anaemia Prevalence and Cognitive Performance Among Schoolchildren in Gujarat, India: A Case-Control Study.” International Journal of Food Sciences and Nutrition 72 (5): 690–703. doi:10.1080/09637486.2020.1855126. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]

Makkar, S., S. Minocha, K. G. Bhat, A. T. John, S. Swaminathan, T. Thomas, M. G. V. Mannar, and A. V. Kurpad. 2022. “Iron Fortification Through Universal Distribution of Double-Fortified Salt Can Increase Wages and Be Cost-Effective: An Ex-Ante Modeling Study in India.” The Journal of Nutrition 152 (2): 597–611. doi:10.1093/jn/nxab378. [Crossref], [Web of Science ®], [Google Scholar]

Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF, and Population Council. 2019. Comprehensive National Nutrition Survey (CNNS) National Report. [Google Scholar]

Ministry of Statistics and Programme Implementation (MoSPI). 2019. Periodic Labour Force Survey. New Delhi: Ministry of Statistics and Programme Implementation, Government of India. [Google Scholar]

Moretti, D., M. B. Zimmermann, S. Muthayya, P. Thankachan, T. Lee, A. V. Kurpad, and R. F. Hurrell. 2006. “Extruded Rice Fortified with Micronized Ground Ferric Pyrophosphate Reduces Iron Deficiency in Indian Schoolchildren: A Double-Blind Randomized Controlled Trial.” The American Journal of Clinical Nutrition 84 (4): 822–829. doi:10.1093/ajcn/84.4.822. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]

National Sample Survey Office (NSSO). 2014. Household Consumption of Various Goods and Services in India 2011–12. [Google Scholar]

Nguyen, P., M. Walia, A. Pant, P. Menon, and S. Scott. 2022. “Changes in Anemia and Anthropometry During Adolescence Predict Learning Outcomes: Findings from a 3-Year Longitudinal Study in India.” The American Journal of Clinical Nutrition 115 (6): 1549–1558. doi:10.1093/ajcn/nqac028. [Crossref], [Web of Science ®], [Google Scholar]

Olson, R., B. Gavin-Smith, C. Ferraboschi, and K. Kraemer. 2021. “Food Fortification: The Advantages, Disadvantages and Lessons from Sight and Life Programs.” Nutrients 13 (4): 1118. doi:10.3390/nu13041118. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]

Pachón, H., B. Reynolds, M. Duong, B. L. Tsang, L. Childs, C. L. Luthringer, Y. Kang, F. C. Vasta, and K. Codling. 2021. “The Potential Contribution of Fortified Maize Flour, Oil, Rice, Salt, and Wheat Flour to Estimated Average Requirements and Tolerable Upper Intake Levels for 15 Nutrients in 153 Countries.” Nutrients 13 (2): 579. doi:10.3390/nu13020579. [Crossref], [Web of Science ®], [Google Scholar]

Peña‐Rosas, J. P., P. Mithra, B. Unnikrishnan, N. Kumar, L. M. De‐Regil, N. S. Nair, M. N. Garcia-Casal, and J. A. Solon. 2019. “Fortification of Rice with Vitamins and Minerals for Addressing Micronutrient Malnutrition.” Cochrane Database of Systematic Reviews 10. doi:10.1002/14651858.CD009902.pub2. [Crossref], [Google Scholar]

Plessow, R., N. K. Arora, B. Brunner, C. Tzogiou, K. Eichler, U. Brügger, and S. Wieser. 2015. “Social Costs of Iron Deficiency Anemia in 6–59-Month-Old Children in India.” PLoS One 10 (8): e0136581. doi:10.1371/journal.pone.0136581. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]

Prieto-Patron, A., Z. V. Hutton, G. Fattore, M. Sabatier, and P. Detzel. 2020. “Reducing the Burden of Iron Deficiency Anemia in Cote D’Ivoire Through Fortification.” Journal of Health, Population, and Nutrition 39 (1): 1–15. doi:10.1186/s41043-020-0209-x. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]

Rai, R. K., S. S. Kumar, S. S. Gupta, D. J. Parasannanavar, T. S. N. Anish, A. Barik, R. K. Varshney, and H. Rajkumar. 2022. “Shooting Shadows: India’s Struggle to Reduce the Burden of Anaemia.” The British Journal of Nutrition 1–12. doi:10.1017/S0007114522000927. [Crossref], [Web of Science ®], [Google Scholar]

Rajagopalan, S., and M. Vinodkumar. 2000. “Effects of Salt Fortified with Iron and Iodine on the Haemoglobin Levels and Productivity of Tea Pickers.” Food and Nutrition Bulletin 21 (3): 323–329. doi:10.1177/156482650002100313. [Crossref], [Google Scholar]

Robinson, L. A., J. K. Hammitt, M. Cecchini, K. Chalkidou, K. Claxton, Cropper, M. 2019. Reference Case Guidelines for Benefit-Cost Analysis in Global Health and Development. Boston, MA: Center for Health Decision Science, Harvard TH Chan School of Public Health. [Crossref], [Google Scholar]

Sachdev, H. S., A. Porwal, R. Acharya, S. Ashraf, S. Ramesh, N. Khan, U. Kapil, A. V. Kurpad, and A. Sarna. 2021. “Haemoglobin Thresholds to Define Anaemia in a National Sample of Healthy Children and Adolescents Aged 1–19 Years in India: A Population-Based Study.” Lancet Glob Health 9 (6, Jun): e822–831. doi:10.1016/S2214-109X(21)00077-2. [Crossref], [Web of Science ®], [Google Scholar]

Sarna, A., A. Porwal, S. Ramesh, P. K. Agrawal, R. Acharya, R. Johnston, N. Khan, et al. 2020. “Characterisation of the Types of Anaemia Prevalent Among Children and Adolescents Aged 1–19 Years in India: A Population-Based Study.” The Lancet Child & Adolescent Health 4 (7): 515–525. doi:10.1016/S2352-4642(20)30094-8. [Crossref], [Google Scholar]

Scott, S. P., L. E. Murray-Kolb, M. J. Wenger, S. A. Udipi, P. S. Ghugre, E. Boy, and J. D. Haas. 2018. “Cognitive Performance in Indian School-Going Adolescents is Positively Affected by Consumption of Iron-Biofortified Pearl Millet: A 6-Month Randomized Controlled Efficacy Trial.” The Journal of Nutrition 148 ((9)): 1462–1471. [Crossref], [Web of Science ®], [Google Scholar]

Swaminathan, S., S. Ghosh, J. S. Varghese, H. S. Sachdev, A. V. Kurpad, and T. Thomas. 2019. “Dietary Iron Intake and Anemia are Weakly Associated, Limiting Effective Iron Fortification Strategies in India.” The Journal of Nutrition 149 (5): 831–839. doi:10.1093/jn/nxz009. [Crossref], [Web of Science ®], [Google Scholar]

Thimmayamma, B. V. S., P. Rau, and K. Damayanti. 2016. “Dietary Assessment as Part of Nutritional Status.” In Textbook of Human Nutrition, edited by M. Bamji, K. Krishnaswamy, and G. Brahmam, 4th ed., 121–151. New Delhi (India): Oxford & IBH Publishing Pvt Ltd. 2016 [Google Scholar]

Thomas, D., E. Frankenberg, J. Friedman, J. P. Habicht, M. Hakimi, Ingwersen, N. 2006. Causal Effect of Health on Labor Market Outcomes: Experimental Evidence. [Google Scholar]

WFP. 2021. State of School Feeding Worldwide 2020. Rome: World Food Programme. [Google Scholar]

WHO. 2011. Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. Vitamin and Mineral Nutrition Information System, Geneva, World Health Organization, (WHO/NMH/NHD/MNM/11.1). accessed January 16. [Google Scholar]

World Bank. 2022. Fortification of rice with iron provided under the Social Safety Net in India: a cost-benefit analysis. [Google Scholar]

World Population Prospects. 2019. United Nations Department of Economic and Social Affairs Population Dynamics. https://population.un.org/wpp/. [Google Scholar]